Source:1 https://www.leicspart.nhs.uk/autism-space/all-about-autism/why-autism-can-be-difficult-to-recognise-in-some-people/
Autism is not a ‘one size fits all’ label
Autistic people have similarities in their neurology and thinking styles. These can be generalised and broken down into categories – which can help our understanding of autism and autistic people.
The main areas of difference are with the following:
- communication, interaction, and relationships
- sensory processing
- a need for predictability, sameness, and repetition
- intense thinking and interests
- information processing
- executive functioning
Below are some symptoms of Autism, but girls may experience symptoms in a different way than boys, and in a way that is not “typical” making it difficult to recognise.
Why Autism can be difficult to recognise in some people
When autism was first recognised, most diagnosed autistic people were from the white, male heterosexual population – and autistic women and girls were thought to be rare by comparison.
- A leaflet by the autistic girls network – ‘Keeping it all inside’ https://autisticgirlsnetwork.org/wp-content/uploads/2022/11/Keeping-it-all-inside.pdf
Historically, research into autism was mainly focused on the white, heterosexual, cis male population. Research about autism in non-male, non-white, gay and bisexual populations is relatively new by comparison. Although, it seems to be becoming more evident that there are many more autistic people who do not fit into this group.
Therefore, many researchers now believe that there are numerous autistic people in the following categories:
- People in the LGBTQI+ population – such as gay, bisexual and trans people
- Women, girls, and non-binary people
- People from a non-white ethnicity
As research develops, it is becoming apparent that people who fall into the above categories may often present differently from typical white, heterosexual, cis male autistic people.
Any autistic person with a non-typical presentation has the same core characteristics as most autistic men and boys – rooted in neurological differences (differences in ‘brain wiring’). This is what causes the differences in information processing and leads to differences in observable behaviours.
It is these observable behaviours which can seem quite different when comparing one autistic person to another – or even one group of autistic people to another.
It is important to stress that this is a generalisation; it may be that autistic people in different demographic groups tend to have observable behaviours that are less obvious and fundamentally different from that of white, heterosexual cis males – due to differences in culture and socialisation.
Evidence also suggests that autistic people outside of this demographic tend to be more prone to and adept (skilled) at masking – and hiding or internalising their difficulties. Again, to generalise, we might guess that this could be due to them being less privileged and/or more vulnerable, by comparison – and therefore they are more likely to mask as a protective mechanism.
See article on masking https://www.leicspart.nhs.uk/autism-space/health-and-lifestyle/masking-just-the-facts/
When it comes to autism assessments, clinicians must decide if the person meets diagnostic criteria. These are observable behaviours which have been largely based on autistic people who fit the very narrow white, heterosexual cis male population. Assessors tend to use standardised observations and reports of behaviours to determine if a person is considered to meet these criteria and may not always manage to find out about the person’s thinking style that underlies their behaviour. This can mean that an autistic person who is not from this group may behave in ways that do not seem to fit the autism diagnostic criteria.
Even some white, heterosexual, cis males may not be recognised as autistic if they do not conform to the standard stereotype. For instance, any autistic person who happens to be skilled at studying socially expected behaviours and / or who has good spoken language skills can be mistaken for being neurotypical.
Therefore, this can indicate that some autistic individuals who have a non-typical presentation of autism remain undiagnosed – and in some cases even misdiagnosed. This often suggests that they are misunderstood by themselves and by others. Consequently, this group are unlikely to access the most beneficial advice and support – which in turn can lead to poor emotional health and wellbeing, difficulties accessing education and employment, and more likely to have relationship difficulties.
It is known that autistic people have a higher-than-average chance of having mental health difficulties, such as anxiety or depression. They also have a higher-than-average chance of having an eating disorder. In some instances, undiagnosed autistic people who have any of these types of problems might simply be diagnosed with mental health difficulties or eating disorders and the autism is missed. This is known as diagnostic overshadowing.
When autistic people remain undiagnosed and unsupported this is usually due to the bias of an outdated stereotype and the incorrect assumptions which occur as a result.
These assumptions can lead to lack of understanding from a range of otherwise well-meaning people including parents, partners, health professionals, schools and employers.
This is slowly beginning to change as the knowledge around these differences increases and is becoming more widely discussed.
Autistic people who are not white, heterosexual cis males…
- are more likely to have intense interests that are shorter lived and/or on trend and/or socially acceptable.
- might speak with a high-pitched tone or an unusual ‘sing song’ voice
- might stim in a way that is less obvious and more typically socially acceptable – for example, hair twisting.
- are more likely to internalise their autistic type thinking rather than expressing this through their behaviour.
- Are more likely to appear withdrawn rather than aggressive – and are more likely to apologise and try to appease if they are felt to have made an error.
- May seem sociable but can often find this difficult.
- Can come across as shy or at other times may appear to be bossy and overly direct in their communication style, which can seem confusing.
- May often use masking – and may not always do this consciously. The ongoing stress of continually masking can result in anxiety and overwhelm. They may mange to suppress this until they are in their safe spaces where they may then find themselves having meltdowns and / or shutdowns. It is quite common for autistic people who mask to manage this all day at school or work – and then coming home and feeling the need to release pent up stress or energy.
- The types of repetitive behaviours they tend to do may be different compared to typically white, heterosexual cis make autistic people. They may tend to re-do tasks until the results are ‘perfect’ to them. Striving for perfectionism can be viewed by educators or employers as being a ‘textbook’ student or ‘model’ employee.
- They may tend to internalise negative and confusing feelings, leading to detrimental impact on their emotional health and wellbeing – and potentially may lead to diagnostic overshadowing.
- They might have friendships – and are more likely to be part of a small, supportive friendship group, which they are happy to follow.
- They may often demonstrate empathy and compassion to others.
- They may often struggle in larger groups – finding this more stressful and confusing.
- They can find non-verbal social signals confusing.
- They are more likely to have friendship issues when shared interests change.
- They may find it harder than most to cope emotionally when friendships evolve or end.
For further information
A leaflet about girls and autism – ‘Flying under the radar’ https://www.leicspart.nhs.uk/wp-content/uploads/2024/06/girls_and_autism_-_flying_under_the_radar-1.pdf
Click here to view the National Autistic Society page on women and girls
Click here to view the National Autistic Society information about autism in the BAME community
Click here to read about double discrimination for black, autistic children in schools
Click here to read a blog by a black, bisexual, autistic person
Click here to see Michael Fuller – a black autistic boy who can ‘download’ music into his head
Many neurodevelopmental conditions can often exist together, but each can be treated in different ways. The picture below illustrates how the conditions overlap. There can also be an overlap between Autism and PTSD/Complex PTSD.
Coping with Autistic Fatigue and Burnout
Executive Functioning
The link between joint hypermobility and neurodiversity is discussed in the videos below and in some research papers4
Stimulation of brain mast cells and/or microglia by a combination of environmental and stress triggers may be altering the normal “fear threshold” (Figure 1). This process could explain at least part of the pathogenesis of ASD. 5
ASD may have a link to MCAS/Dysautonomia in some – more likely if comorbodid EDS
Harvard: 6Autistic people are four times more likely to experience depression during their lifetime than the general population. Signs and symptoms of depression in both neurotypical and autistic patients include:
- feelings of sadness, tearfulness, emptiness or hopelessness
- Angry outbursts, irritability or frustration, even over small matters
- Loss of interest or pleasure in most or all normal activities, such as sex, hobbies or sports
- Sleep disturbances, including insomnia or sleeping too much
- Tiredness and lack of energy, so even small tasks take extra effort
- Reduced appetite and weight loss or increased cravings for food and weight gain
- Anxiety, agitation or restlessness
Therapeutic Treatment for anxiety and depression
Self-advocates and autistic people who feel comfortable sharing their feelings can benefit from talk therapy. It’s important to consider the best strategy for understanding and treating anxiety or depression according to the needs of the autistic person. Some approaches to treating anxiety and depression include cognitive behavioral therapy (CBT), mindfulness therapy, dialectic behavioral therapy (DBT), and neurofeedback.
Medication Treatment for anxiety and depression
Medication and autism is a complex topic. Prescription, over the counter, and complementary medications don’t always work for all patients and side effects can affect long-term health. Clinicians who treat autistic patients often find that medications and dosages that work well for neurotypical patients are less effective for those with autism. It’s important to discuss medication strategies with the PCP or any prescribing clinician to ensure that any psychotropic medications are tailored specifically to the unique needs of the autistic patient.
For example, Selective Serotonin Reuptake Inhibitors (SSRIs) are often used as a first line medication for anxiety in neurotypical patients. However, some experts in the autism field caution against their use in autistic patients, especially children and adolescents. Buspirone and mirtazapine in very small doses to start have been shown to help anxiety, with slow and steady dosing up to a typical amount.
Harvard Medical School’s free Clinician Course for medical providers, Clinical Care for Autistic Adults, (https://cmecatalog.hms.harvard.edu/clinical-care-for-autistic-adults) provides clear and extensive advice to medical providers about best practices for treating autistic adults, including specific guidelines for medication.
Another useful resource is the Parent’s Medication Guide from the American Psychiatric Association
Australian Family Physician RACGP.org.au 7
Sensory processing differences are now included within the diagnostic criteria for ASD.1 Heightened or lowered tolerance to sound, vision, touch, movement, taste and smell can be experienced by individuals with ASD.
Inability to tolerate sensory input can have an impact on the adult’s ability to participate in the community, and have significant implications for their mental health (eg as a driver of anxiety and avoidance symptoms).
Referral to an occupational therapist for a sensory assessment and therapy may be useful. However, practitioners should be aware that evidence for the effectiveness of sensory interventions is limited at this time. In view of issues with sensory tolerance, adaptations to consultation rooms in general practice may improve the consultation experience for adults with ASD.
These include avoiding fluorescent lighting, dimming the lights, reducing visual distractions, minimising auditory distractions including those from machines and loud ticking clocks, providing a comfortable chair, and fidget, tactile and/or weighted items that the person may hold or touch to aid in self-regulation.
- All about Autism NHS https://www.leicspart.nhs.uk/autism-space/all-about-autism/ ↩︎
- Autism, Girls, & Keeping It All Inside https://autisticgirlsnetwork.org/wp-content/uploads/2022/11/Keeping-it-all-inside.pdf ↩︎
- https://www.attwoodandgarnettevents.com/blogs/news/20-tips-for-managing-anxiety-for-autistic-individuals ↩︎
- Csecs JLL, Iodice V, Rae CL, Brooke A, Simmons R, Quadt L, Savage GK, Dowell NG, Prowse F, Themelis K, Mathias CJ, Critchley HD, Eccles JA. Joint Hypermobility Links Neurodivergence to Dysautonomia and Pain. Front Psychiatry. 2022 Feb 2;12:786916. doi: 10.3389/fpsyt.2021.786916. PMID: 35185636; PMCID: PMC8847158. ↩︎
- Theoharides, Theoharis C., Maria Kavalioti, and Irene Tsilioni. 2019. “Mast Cells, Stress, Fear and Autism Spectrum Disorder” International Journal of Molecular Sciences 20, no. 15: 3611. https://doi.org/10.3390/ijms20153611 ↩︎
- https://adult-autism.health.harvard.edu/resources/anxiety-and-depression/ ↩︎
- https://www.racgp.org.au/afp/2015/november/management-of-mental-ill-health-in-people-with-aut ↩︎